(Editor’s note: apologies if you’re on my email list and receiving this a second time. It won’t happen too often. If you’re not on my email list, you should be! Please write “SUBSCRIBE” to laura@jevaia.org).

Good morning from sunny Pokhara! I arrived yesterday and enjoyed a nice homecoming tour of all my regular haunts. Since August, Pascal has rigged up a home-made antenna on the roof, Aidan’s other front tooth has finally come in, and the corn has been cut down in the garden in front of our office, replaced with new seedlings. I absolutely love this season in Nepal – the cold, wide air, the clear mountain skyline which is obscured by fog during the monsoon, the evening snuggles with my nephews under warm blankets. Tonight I head up to beautiful Kaskikot to see Aamaa.

I’m so excited to tell you about our plans for this winter. After 10 years of chipping away at all this, we are just days away from a two-week collaboration with dentists, researchers, and students from Berkley, UCSF, UConn and the University of Puthisastra in Cambodia. It is a strange and wonderful feeling to be preparing for such a large and qualified group of visitors after so many years of working away with few outside witnesses to our efforts. There are many great things wrapped up in upcoming this ball of projects.

The first is helping to implement a UCSF/Berkley study of oral health and nutrition in mothers and their children. Our own JOHC field teams will get to work with the researchers to conduct this study in one of our villages. The second project is training our technicians in some new techniques, which they’ll incorporate in to their sustainable clinics. Third, we have the chance to bring dentists to our rural clinics for medical audits. Believe it or not, after an entire decade, this will be the first time we’ve had foreign dentists come to visit our clinics.

And finally, we’re going to pilot an evaluation of past patients who’ve been treated by our technicians over the years. If you don’t think that sounds like Christmas, listen here! This means comparing the outcomes achieved by our local dental technicians to the results produced by fully credentialed dentists in prior studies of the same treatment techniques. This is a HUGE step towards our goal of having Nepal’s national health care system adopt rural dental clinics in to all of its health posts. Why? Thank you for asking! Because the main criticism is that community-level health workers aren’t qualified to perform dental medicine…even though that excludes millions of people from care. But we’re making the case that, rather than write off local health workers, the medical field must find ways to properly train them to provide the best care possible in their settings. And that’s what we’re doing!

Ok, so those are the technical points. Now let’s talk about me organizing for fourteen people to show up next week from California, Connecticut, India and Cambodia. We have a schedule, a budget, a training plan, hotels, flights, and t-shirts. We’re doing our best to keep things under control. But we are up against the entropy of Nepal, people. THE ENTROPY OF NEPAL. Pretty much anything could derail our plans and contingency plans: a wedding, a political strike, rain, someone’s grandpa dying, a forestry meeting, a buffalo falling ill. A buffalo having a baby. A traffic jam. A flat tire. Lost luggage. Fog on Sunday afternoon. Somebody decided to drive this point home for me at the recently renovated, lusciously carpeted arrival terminal in the Kathmandu airport, which has a new row of fancy kiosks for visa filing:

On the plus side, sometimes fate works to your advantage. Consider our office. This fall, our landlord’s son got married. The son received a number of couches by way of dowry. They don’t fit in our landlord’s apartment, so I arrived to find them in our office, which now looks rather like a furniture store. If you have any idea how much I have obsessedover the setup of our office, you will especially appreciate this stroke of….er….luck…

The only question I get asked more often than if we need dentists (answer: YES! as mentors and teachers for Nepali technicians) is if we need donations of toothbrushes or paste. While that’s a conservative yes, because we provide a limited number of those supplies to schools, most of the time, the answer is, not really, unless they are donations of something purchasable in Nepal. Because, if you think about it for a second, it’s pretty obvious that going to some village and handing out a bunch of disposable hygiene products once might make for good photos, but it doesn’t do much for anyone who needs to use these items every day forever.

Instead, one of the four core activities in JOHC is called Vendor Outreach, where we work with village shopkeepers to make sure that dental hygiene products are locally available and affordable, the same way sugar, salt, incense, and laundry soap are.

In the past, vendor outreach has mainly consisted of having local JOHC teams – i.e. residents – visit the shops in their villages, look at products, talk to vendors about fluoridated toothpaste, and sometimes put up posters or stickers that help people identify toothpaste with fluoride. But this summer we’re working on stepping it up. The main reason is that schools need supplies to run their school brushing programs. For that, we provide brushes and paste on a declining schedule, but by the end of two years, either students or the schools have to finance $1 per student per year to run their brushing programs permanently. Even though this is extremely inexpensive, our experience has been that when supplies run out, often schools just don’t replace them. If we want schools to buy brushes and paste, they need to be extremely easy to get.

Therefore, in June, we started Vendor Outreach 2.0 by looking for the best-priced wholesale distributors in Pokhara, with the idea of setting up a direct link between village shopkeepers and the best possible deal on dental care products. But when we approached our first shopkeeper with this idea he told us he already buys his supplies from a wholesale truck that comes through his village on a regular schedule.

Ok, we said, could we get the truck to go to the best-priced wholesale places? We showed the vendor the prices. The vendor showed them to his truck guy. The truck guy offered a better rate.

So that was over.

Onward, then, to Salyan, one of our harder-to-access regions, where Gaurab was organizing a vendor outreach program for the following week. He had a list of about 25 shopkeepers and their phone numbers. It occurred to us that we should invite school teachers also, since the point was for the teachers who run the brushing programs to connect with the vendors who supply the products they need. This stroke of insight made us feel brilliant. Actually, that was a really good idea.

Before the Gaurab’s trip out to Salyan for Vendor Outreach 2.0, I suggested that he print out little slips of paper with the location and contact info of the best wholesalers we’d found in Pokhara. That way we’d make sure all Salyan’s shopkeepers had this info in a nice tidy fashion. For the best deal.

“So how’d it go?” I asked Gaurab back in the office on Tuesday.

“Great,” he says. “We had over 20 vendors and a lot of the teachers running their school brushing programs came too. We made visits to a number of shops, and I brought the poster with the fluoridated toothpaste packages.”

Vendor Outreach in Salyan

“Awesome, did you give out the contact info for the wholesalers?”

“Yes but…”

“What?”

“I mean, they said they already get brushes and paste at that rate from their wholesale trucks.”

“Are you serious?”

“They said they can totally visit the wholesalers we found if they happen to come to Pokhara,” he consoled me.

“So basically, we’ve spent the whole summer on this, and what you’re saying is…village shopkeepers already get brushes and paste at wholesale prices from trucks that deliver right to them.”

“Yes.”

“All these schools already have vendors down the street with access to these products at the cheapest prices we can find.”

“Yes.”

“…So Vendor Outreach is basically just…getting the teachers up the street together with vendors, and convincing them to purchase supplies down the street.”

“Yes.”

“Like all we have to do is get everyone together and talk about it. Maybe assign a specific shop to each school.”

“Pretty much,” Dilmaya chimes in.

“Guys,” I said.

“I mean, they can use the wholesalers we found if they come to Pokhara,” Gaurab reminded me comfortingly.

“Why is everyone going around handing out free dental supplies?” I demanded to nobody.

Back to the drawing board.

We find this over and over. Our complicated ideas for fixing things are 99% irrelevant, with a critical 1% of something that is missing: information, a tool, a little encouragement, some social integration, a familiarizing element or formality. Vendor outreach will continue to involve oral health education for shopkeepers, because most people are not aware of the importance of fluoridated toothpaste in preventative care. But then it’s mostly a matter of building relationships between vendors and purchasers–especially between schools and specific local shops to source the supplies for their very affordable brushing programs.

In other words, we need tea parties more than we need supply chains, more than we need products, more than we need anything that’s not already there.

In conclusion, we’ll enthusiastically be taking donations of items such as art supplies for oral health games in schools, certificates of achievement for Oral Health Coordinators, funds we can spend on having local tailors sew brush holders, holding workshops, lobbying local leaders, creating teaching materials; and actually, if anyone wants to offer rides to our field officers out to Sindure and Rupakot and Salyan so they don’t have to spend so many hours walking or stuck on buses, that’d be great. Also, snacks. Help us out – there are many things we need to do our part well, and lots of opportunities to support communities in Nepal.

As far as brushes and paste though, I think local shopkeepers figured this out quite some time ago. Duh.